09685 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FI CATION PERMIT NUMBER
vUILDIN �,I ADDRESS APPLICATION & PERMIT n^^n r
f�
:2 BUILDING -ELECTRICAL-PLUMBING -MECHANICAL y b�`�
OWNER'S - PLAN CHECK VALIDATION
NAME
• _ CITY. ELECTRIC PERMIT FEE
\ PHONE
NAME CU"THAcrors UTLETS-SWITCHES-RECEP 10.00/1.00III JA
LIC.No.44-713 1�3 LIGHTING FIXTURES 10.00/1.00 4
roNTRAc O 's APPLIANCES-RESIDENTIAL 4.00
�( ADDRESS
✓/� 4AX PHONE PANELS 10.00 7/ DATE OF APPLICATION
ARCHITECT�Nn `-�t ��I� PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.G NO.
OR T�
ENGINEER
LIC.No. SIGNS TRANS. 3.00
AROH.OR END, SPECIAL CIRCUIT 5.06 v PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 20.00 -, J
AE - - MOTORS SEE FEE SCH. , U
ADDRDDRESSSS
In
i SERVICE CHANGE 20.00 / ('
S, o LICENSED CON TRACTORS DIiCLARATION TEMP.POLE -30.00
K u u I hcrchy affirm "hal I am licensed ender provisions of Chapter 9 ISSUANCE DATE
m Q m (Commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F w z Professions CoAyuYhy license is in full for mt� t ❑ ❑ ❑
license Cluxs_(._I-Q_Lia Number
o z H Dutc_L�-O-b�Cn nlruc"or
Q y s 1 OJ BUILDING PERMIT
¢ a w¢ OWNER-BUILDER DECLARATION INFORMATION
w0 o e' MISC.- REFER TO ORD
g m I hereby ul'finn flnn I am exempt (neat the Contractor's License
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